Barriers and Facilitators To making it Happen!

Daren K. Heyland Professor of Medicine Queen’s University, Kingston General Hospital Kingston, ON Canada

Disclosures

Research Contracts with the Following Companies

•

Nestle

•

Baxter

•

Fresenius Kabi

•

Abbott Nutrition

Results of 2007 International Nutrition Practice Audit

Average time to start of EN :

46.5

hours (site average range: 8.2-149.1 hours) In patients with high gastric residual volumes:  use of motility agents

58.7%

(site average range: 0-100%)  use of small bowel feeding

14.7%

(range: 0-100%) Cahill N Crit Care Med 2010 (in press)

Adequacy of EN: Kcals

Relationship Between Increased Calories and 60 day Mortality

BMI Group Overall <20 20-<25 25-<30 30-<35 35-<40 >=40 Odds Ratio 0.76

0.52

0.62

1.05

1.04

0.36

0.63

95% Confidence Limits 0.61

0.95

0.29

0.44

0.75

0.64

0.16

0.32

0.95

0.88

1.49

1.68

0.80

1.24

P-value 0.014

0.033

0.007

0.768

0.889

0.012

0.180

Legend: Odds of 60-day Mortality per 1000 kcals received per day adjusting for nutrition days, BMI, age, admission category, admission diagnosis and APACHE II score.

Alberda Int Care Med 2009;35:1728

60 50 40 30

Relationship of Caloric Intake, 60 day Mortality and BMI BMI

All Patients < 20 20-25 25-30 30-35 35-40 >40 20 10 0 0 500 1000

Calories Delivered

1500 2000

A Qualitative Assessment of “Barriers and Facilitators” to Implementing Nutrition CPGs in ICU

 Multiple case study  4 case ICU sites  Purposeful sampling  Semi-structured key informant interviews (n=28)   Min. 5 years ICU experience Employed at case ICU site May 2004  Document review Jones NCP 2007;22:449

Potential Barriers

 Resistance to change  Patients clinical condition  Lack of awareness  Information overload  Weak evidence  Resource constraints  Slow administrative process  Impractical / Complex  Nursing workload  Limited critical care experience

Potential Facilitators

 Agreement of the attending physician & ICU team  Part of routine practice  Dietitian / Opinion leader  Access / Visibility  Easy to follow and perform  Provision of education  Open discussion

Favored Implementation Strategies

 Informal one-on-one discussions  Academic detailing, ward rounds  Protocols  Pre printed orders, Check-list, algorithms,  Bed-side reminders  Feedback and audit  Site reports

The Impact of Enteral Feeding Protocols on Enteral Nutrition Delivery: Results of a multicenter observational study

 International, prospective, observational, cohort studies conducted in 2007 and 2008 from 269 Intensive Care Units (ICUs) in 28 countries    Included 5497 mechanically ventilated adult patients > 3 days in ICU Sites recorded the presence or absence of a feeding protocol Sites provided selected nutritional data on enrolled patients from ICU admission to ICU discharge for a maximum of 12 days.

78% of sites reported use of Feeding Protocol

P<0.05

Heyland JPEN 2010 ( in press)

Initial Efficacy and Tolerability of Early Enteral Nutrition with Immediate or Gradual Introduction in Intubated Patients

• This study randomized 100 mechanically ventilated patients (not in shock) to Immediate goal rate vs gradual ramp up (our usual standard).

• The immediate goal group rec’d more calories with no increase in complications Desachy ICM 2008;34:1054

The Efficacy of Enhanced Protein-Energy Provision via the Enteral Route in Critically Ill Patients: The PEP uP Protocol!

      Not all critically ill patients are the same; we have different feeding options based on hemodynamic stability and suitability for high volume intragastric feeds.

Use semi elemental solution In select patients, we start the EN immediately at goal rate, not at 25 ml/hr.

We target a 24 hour volume of EN rather than an hourly rate and provide the nurse with the latitude to increase the hourly rate to make up the 24 hour volume.

Tolerate higher GRV threshold (250 ml or more) Motility agents and protein supplements are started immediately, rather than started when there is a problem.

A Major Paradigm Shift in How we Feed Enterally

The Efficacy of Enhanced Protein-Energy Provision via the Enteral Route in Critically Ill Patients: The PEP uP Protocol!

Figure 2.1 Adequacy of Calories from EN (Before Group vs. After Group on Full Volume Feeds)

100 90 30 20 10 0 80 70 60 50 40 1 2 5 6 7 PLOT 3 4 ICU Day Before Group After Group

P-value Day 1

0.049

Day 2

0.0005

Day 3

0.17

Day 4

0.31

Day 5

0.60

Day 6

0.34

Day 7

0.20

Total

0.015 Heyland (in submission)

The Efficacy of Enhanced Protein-Energy Provision via the Enteral Route in Critically Ill Patients: The PEP uP Protocol!

Figure 2.2 Adequacy of Protein from EN (Before Group vs. After Group on Full Volume Feeds)

120 110 100 90 80 70 60 50 40 30 20 10 0 1 2 5 6 7 PLOT 3 4 ICU Day Before Group After Group

P-value Day 1

0.014

Day 2

<0.0001

Day 3

0.0015

Day 4

0.13

Day 5

0.57

Day 6

0.62

Day 7

0.34

Total

0.002 Heyland (in submission)

Need for Constant Reminders

Poster

Reminder

HOB sticker

Reminder

screensavers

Special DVD presentation

Early Enteral Nutrition in the ICU: The Clock Is Ticking!

Daren K. Heyland, MD, FRCPC, MSc

Professor of Medicine Queen’s University Kingston, Ontario

www.criticalcarenutrition.com

Overall Site Performance

Practice Changing Interventions

 Protocolize/automate care  Improve organizational culture  Develop Dietitian and other KOL as local opinion leaders  Audit and feedback with bench-marked site reports  Assess barriers and have interactive workshops with small group problem solving  Implement strategies with rapid cycle change (PDSA)  Educational reminders (manuals, posters, pocket cards)  One on one academic detailing

What works best at your site?

(barriers and enablers will vary site to site)

What is already working well at your site?

(strengths and weakness are different across sites)

Conclusions

 Long way to go to narrow the quality gap  Need to enrich our understanding on how best to achieve that; but in the mean time, act now!

 With our emerging understanding of the problems, we need to develop more targeted or strategic solutions.

 Strengths & weaknesses; barriers & enablers vary across sites.

 Stay tuned…